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HomeMy WebLinkAbout1664A (223) � WORKERS'COM7ENSATION DECLARATION � APPL'CATION FOR PERMIT � �� ��ryqq��' I hereby af{i�rm that I have o certificote of consent to self � insure,or a cer�ificare of Workers'Compensation Insurance, ��36nC HEATING - VENTILATING - AIR CONDITIONING or a c�riified wpy thereof(Sec.3800,Lab.C) CE-818(REV.10/81) Paol�icy No. Company Cenified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is filed with the county building inspec- FOR APPLICAN7 TO FILL IN BUILDING .. � � ,� -� tion department. ADDRE55 (PRINT OR TYPE ONIY) Dote Applicant LOCALITv NO. TYPE OF APPLIANCE OR FQUIPMF.Ni FEE CERTIFICATE Of EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. F� �� . A6SORPTION UNIT,B�U (This secfion need not be completed if fhe work involved by nisruiu No i�uocesseo ov }he permii is far one hunflred dollars(�100�or Icss,� AIR HANDLING UNIT,CFM I certify Ihal in the performance af the work for which ihis i�I ^��� �-.,. permit is issued,I shall not employ ony person in any manner ; so as to em e subject to the W e � pensation aws. sonee,aTu nroenvAu nnrF r i'sarcioa-s;i�Nnruer .x Dote Appl icanf ' �1•l COMPRESSOR,BTU ���`'�� ��j ROUGH � � /, 2Z? �,, � � �.. -�:,--,i : NOTICE TO A PLICANT: If, afler making this Cerlificate of VENTILATION SYSTEM hWAI �J' :' I.r�,�� ' . Exemptian, you should become subject to the Workers' -- Compensotion provisions of the Lobor Code,you must forth- EVA70RAiIVE COOLER VI411�qTION� with mmply with such provisions or this permii shall be — . deemed�evoked. � FURNACE: rAU viiv ����� LICENSE�CONiRACTORS DECLARAiION FIOOR g7�� � L' � I hereby affirm that I am licensed under provisions of Chapter 9 HF.ATER�. SUSPFNDED UNIT_ (rommencing with Section 700D)of Division 3 of+he Business � '/�A�i and Professions Codc,ond my license is in full force ond effect. } A 0. License Number���Li�.Cl�ss����Q o ,� _> � ► FJ Contractor QS����y"-.a Date ��� � ❑ — � I om exempt under Sec. V cta I P an c eck fee I � 8.8P.C.for ihis reasan p��p PERMIT ISSUING FEE$ �.) ? Signo�ure TOTAL PEE OWNER BVILDF.R DECLARATION PIAN CH(IX APPLICANT I here6y aihrm thaf I�m exempt from�he Conirattor's License , Law for ihe following reason(Section 7031.5, Rusiness and NAME Professions Code), ❑ !, as owner oi the oroperfy, ar rny emplayees svith ADUNE55 wages as their sole mmpensation,will do Ihe work ond the struc!ure is not intended or offered for sale(Sec�ion ��TY TFL.NO ,. '; �f.;,. � 7044,Business and Professions Codej. � OWNER � �'^L�„� � �� y n c m a a�; ❑ I,as owner of the propeny,am exdusively mntracting v� with licensed coNractors to ronstrurt ihe project(Seo- MnIL n c tion 7044,Business ond Professwns Code). AD�RE55 �-�, j a n.`��� ``;C; CONSTRUCTION LENDING AGENCY CITY � `�� TEL.NO.�� '� ^ �q ��.�� 1,;rr i I hereby affirm Ihat there is a construciion Iending agency for � � � ihe performance of the work for which this permit is issued CONTRACTOR (Sec.3D97,Civ.C.). �� S� �?C�m`C''b ADDRE'� �� /�� Lender's Nome L CIIY r � TEL.NO. •'�' �) ' Lender's Address ! C STATf. LIC I certify that I have read this applicatiun and st�ie that the LiCENSE NU �� CLASS '"� above Informotion Is wrred.I agree to mmply wilh oll Counly ordinances and State laws relatinc�to building construction, a here thorize rep sentotives of his County to enier u o t e bo e-mentio properry for �spe fion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE n I, �. 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